Upon application made to the Court today by the above named applicant under section 43A(2) of the above mentioned Act, for an order under section 43A of the said Act in respect of the above named child who appears to the Court to be aged ... years having been born *so far as has been ascertained* on ..... day of ......... and who resides at ............. in said court (area and) district.

THE COURT BEING SATISFIED THAT

notice of the application was duly served

the said child is in the care of the Health Service Executive under *section 4 * section 18 of the Child Care Act 1991 and has been placed with the applicant * under section 36(1)(a) of the said Act as foster parent *under section 36(1)(d) of the said Act as a relative

the said applicant has been taking care of the said child for a period of not less than five years beginning on the date of placement in accordance with the Child Care Act 1991 and ending on the date of application

the granting of the order is in the child's best interests

the Health Service Executive has consented in advance under section 43A(2)(c) of the Act to the granting of the order

*the Health Service Executive has, on behalf of the applicant, obtained the consent under section 43A(2)(d)(i) of the Act to the granting of the order of a parent having custody of the child at the relevant time or a person (other than the applicant) acting in loco parentis to the child, the child being in the care of the Health Service Executive under section 4 of the said Act

*the consent of a parent having custody of the child at the relevant time or a person (other than the applicant) acting in loco parentis to the child under section 43A(2)(d)(i) of the Act to the granting of the order (the child being in the care of the Health Service Executive under section 4 of the said Act), is not required because *such person is missing and cannot be found by the Health Service Executive *the Court, having regard to the child's welfare so directs

*the Health Service Executive has, on behalf of the applicant, given notice of the application under section 43A(2)(d)(ii) of the Act to the granting of the order to a parent having custody of the child at the relevant time or a person (other than the applicant) acting in loco parentis to the child, the child being in the care of the Health Service Executive under section 18 of the said Act

*the notification of a parent having custody of the child at the relevant time or a person (other than the applicant) acting in loco parentis to the child under section 43A(2)(d)(ii) of the Act (the child being in the care of the Health Service Executive under section 18 of the said Act) is not required because *such person is missing and cannot be found by the Health Service Executive *the Court, having regard to the child's welfare so directs

the child's wishes have, so far as is practicable, been given due consideration having regard to the age and understanding of the child

HEREBY GRANTS an order under section 43A of the said Act, which shall, subject to the conditions and restrictions set out in this order, take effect in accordance with section 43A(5) of the said Act.

The Court imposes the following conditions or restrictions as to the authority of the applicant in accordance with section 43A(ó) of the said Act, namely ................. [insert any conditions or restrictions]

Dated this ..... day of ........ 20 ....

Signed .................

Judge of the Children Court

*Delete words inapplicable

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